Perianal ulcers in a human immunodeficiency virus-seropositive man

A 44-year-old man infected with human immunodeficiency virus presented with 1-month history of fever, night sweats, weight loss, and two perianal ulcerations. He had a history of primary syphilis and pulmonary tuberculosis and underwent complete treatment for both diseases. He had never been administered highly active antiretroviral therapy. Physical examination showed a large submaxillary lymphadenitis, two perianal ulcers with indurated erythematous margins and exophytic verrucous lesions compatible with condyloma acuminata or anogenital warts due to human papillomavirus (Figure A). Initial laboratory findings included anemia and high erythrocyte sedimentation (60mm/h). CD4 T-cell count was 107 cells/µL. The colonoscopy was normal and chest computed tomography showed an infiltrate compatible with miliary tuberculosis. Scarification of the perianal lesions was performed; Ziehl-Neelsen stain was positive for acid-fast bacilli (AFB) (Figure B) and Grocott's methenamine silver stain identified numerous fungal intracellular organisms compatible with Histoplasma (Figure C). A skin biopsy revealed granulomatous infiltration with multinuclear giant cells, lymphocytes and histiocytes without necrosis. The culture of skin biopsy smears was positive for Mycobacterium tuberculosis. Direct examination and cultures of sputum, bronchoalveolar lavage and aspiration of the cervical lymph node were positive for AFB and M. tuberculosis. Treatment with the antituberculous first-line drug regimen and amphotericin B resulted in rapid clinical improvement. Two months later, the perianal lesions were completely healed.

Perianal lesions represent a rare form of periorificial cutaneous tuberculosis and an unusual skin manifestation of disseminated histoplasmosis and tend to occur predominantly in patients with AIDS^{1) (2) (3}.

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  Kahi CJ, Wheat LJ, Allen SD, Sarosi GA. Gastrointestinal histoplasmosis. Am J gastroenterol 2005; 100;220-231.

Publication Dates

• Publication in this collection
  Jan-Feb 2016

History

• Received
  12 Aug 2015
• Accepted
  08 Sept 2015